UK government to shift NHS power to community health care

BMJ 2006; 332 doi: (Published 02 February 2006) Cite this as: BMJ 2006;332:253
  1. Zosia Kmietowicz
  1. London

    GPs in England are being charged with developing a “new generation of community facilities” to provide patients with a range of medical and social care services closer to where they live, the government announced this week. The secretary of state for health, Patricia Hewitt, said that she wants to see 5% of the NHS budget for England—£4bn ($7bn; €6bn) a year—transferred from the secondary sector to primary care in the next 10 years. Currently, England spends 27% of its health budget on community services compared with 33% in European countries.

    “People in the NHS have told us for decades about shifting the emphasis of care from acute hospitals to primary care. We believe we can achieve this shift because of the reforms we have introduced and the support of the medical profession,” said Ms Hewitt. “With practice based commissioning and payment by results we are putting incentives into the system to shift resources out of acute hospitals and into the community, with better value for money.”

    New measures proposed in the white paper

    • A simplified system for registering with a GP and a guarantee of a local GP

    • Incentives for GPs who take more patients and for practices that open at more convenient times

    • Improved primary care in underserved deprived areas, possibly by private and voluntary groups

    • Pilot of a new “life check” at certain key ages to assess people's lifestyle risks in two parts: First as an online questionnaire or downloaded hard copy followed by specific advice if needed

    • Joint commissioning of services between primary care trusts and local authorities

    • Support for people with long term conditions to improve self care, including “information prescriptions”

    • Triple the investment in the expert patient programme

    • More support for carers including improved emergency respite arrangements and national helpline

    The white paper on improving community health and care services proposes new community hospitals that would provide diagnostic tests, minor operations, and inpatient care that does not require critical cover. About 50 new or refurbished community hospitals are planned for England. Procedures carried out in primary care cost as little as a third of what they would in secondary care, and, with better management of long term conditions in the community, the aim is to reduce costly emergency bed days in acute hospitals.

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    Power to the people: Prime Minister Tony Blair and Health Secretary Patricia Hewitt have pledged to move health care closer to patients


    We are asking PCTs with closure propositions for cottage hospitals to look at the principles of the white paper and reconsider their plans,” said Ms Hewitt.

    Care pathways in six specialties are also being developed with the royal colleges to see if the conditions can be better managed in the community. Currently, there are nearly 45 million outpatient appointments every year. It has been estimated that up to half of those for dermatology; general surgery; orthopaedics; gynaecology; urology; and ear, nose, and throat services could be provided in the community.

    The change would require hospital doctors to work more closely with GPs but would free consultants to deal largely with more complex cases, said Ms Hewitt. She also signalled an opening up of the market to provide primary care services. Private companies and voluntary organisations would be able to tender for services in parts of the country where there were shortfalls, she said.

    Mayur Lakhani, the chairman of the Royal College of General Practitioners, welcomed the white paper as good news for patients and GPs, calling it “a major step forward in strengthening primary care, with general practice as the backbone of the NHS.”

    “Every effort must now be made by the NHS to engage frontline clinicians, something that has not happened with great success to date. PCTs must ‘let go’ and allow GPs to run flourishing improvement schemes through practice based commissioning schemes,” he added.

    More doctors were also needed if the ambitions of the white paper were to be achieved, said Hamish Meldrum, the chairman of the BMA's General Practitioners Committee. Some parts of England have as few as 40 GPs per 100 000 people, yet others have 70.

    “Many practices are already offering longer opening hours, but there will need to be resources in place to expand this more widely. We cannot stretch our existing workforce any further,” said Dr Meldrum.

    Angela Coulter, the chief executive of the independent healthcare charity the Picker Institute Europe, welcomed many of the proposals in the paper but said that the government had missed an opportunity to tackle unemployment among people with mental health problems. The recommendation of an “information prescription” should include everyone, not just those with long term conditions, she added.


    • The white paper, Our Health, Our Care, Our Say, is available at

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